Panic Disorder Patients Need Us

Clinical Psychiatry News - Volume 36,
Issue
3, Page 29 (March 2008)

After feeling chest tightness, shortness of breath,
and dizziness, the patient got herself to an emergency department.
While waiting to be seen, she experienced profuse sweating that was
accompanied by shaking, tingling, and a sense of impending doom. Could
this be a heart attack? Is she dying?

After more than 25 years of experience,
cardiologist Dr. Edwin Weiss of the New York University Medical Center
knows that some of these patients
are suffering from panicdisorder—a severe type of anxiety
disorder.

In the few cases in which patients have good insight and no
other comorbid psychiatric disorders, Dr. Weiss offers a quick treatment
that simulates the light-headedness and dizziness of panicdisorder. “Under my supervision, I
have them blow in and out of a paper bag, and under their control, they
experience the lightheadedness and dizziness. That shows them that they
can be in control of the attack, rather than letting the attack be in
control of them. For some, this is very helpful,” Dr. Weiss, who has a
vibrant practice in New York, said in an interview.

But Dr. Weiss also refers many patients to psychiatrists. “That's
what I consider good medical care,” he said.

In the 1980s and through the 1990s, “panicdisorder” almost became a
household term, and more people identified their own symptoms and sought
out help, as they do now.

According to a literature review published a
few years ago, 30% of emergency room patients with chest pain, after a
work-up for coronary artery disease, were diagnosed with a panicdisorder (Can. J. Psychiatry
2003;48:361–6). Ninety-eight percent of these panicdisorderpatients were undiagnosed when
first evaluated. Clearly, specialty training and experience are needed
to recognize and treat this disorder.

Managed care insurers would prefer to see
these patients treated on
the cheap by primary care physicians, but primary care physicians have
enough on their hands without treating psychiatric illnesses. Also,
primary care physicians are too quick to offer these patients medical management alone
since they don't have the training or time for in-depth evaluations or
are not equipped to do adequate treatment.

Medication can help greatly, but I believe
that some therapeutic efficacy was lost when tricyclic antidepressants
were replaced by the safer selective serotonin reuptake inhibitors.
Furthermore, it has become clear to me that the anticipatory anxiety,
which can be worse than the panic
attack, can be helped with behavior modification and that starting a
patient on benzodiazepines is sometimes unnecessary.

I have been treating patients with panicdisorder for more than 30 years.
In the early days, I prescribed imipramine for the panic and a benzodiazepine such as
Librium (chlordiazepoxide) or Valium (diazepam) for 2–3 weeks to help patients cope with the
anticipatory anxiety that occurred before the imipramine became
effective. Both behavior modification alone and medications alone
appeared effective. I have found that the combination of medication and
behavior modification often works best, but many patients resist medication, or if
they take it they don't like the side effects, so they can certainly
reap great benefit from behavioral therapies alone in treating their panicdisorder.

The learning, philosophizing, and action
(LPA) technique has become a mainstay of my treatment. Learning about
the disorder with a patient
who has seen doctors other than psychiatrists and visited emergency
departments for their symptoms is a great advantage because they have
been given a clean bill of health. A cognitive challenge can be
presented in the form of possibilities and probabilities, in which, over
and over, we can review that almost anything is possible. The question
becomes: What are the probabilities of dying or going crazy?

After going through several examples in my
cognitive challenge—from the absurd (it's possible the sun won't come up
tomorrow) to the less intense—I ask the patient to develop her own sets
of possibilities and probabilities. At the end of her sets of examples,
I prefer to have her end with a defining set that centers around the
overwhelming anxiety that permeates her thinking in anticipation of a panic attack.

As automatic thoughts of anxiety and panic are explored in a newer
perspective from the patient's own thinking, it appears that a
desensitization process occurs. Together, we learn how to challenge
thoughts of terror when there is none. We can philosophize about the
origins of panicdisorder, from a learned
experience to a genetic loading, and sometimes just talking about it is
helpful. Beware of slipping into the traditional weekly open-ended
psychotherapy that gets to a lot of issues but sometimes fails to
address what the patient wants treated.

In addition to this cognitive restructuring, I
spend three or four visits with the patient beginning a
relaxation/behavior modification program using relaxation, systematic
desensitization, and reciprocal inhibition. Again, I am comfortable
using the split-screen technique with visualization of anxiety, fear,
and panic on the left side
of the screen and a pleasant relaxing set of experiences on the right
side.

The patient learns this technique, practices,
and often becomes the master of the disorder. As I develop the
strategy for panic attack
treatment and resolution, I incorporate the same strategies for those
who also suffer concurrently from agoraphobia, using possibilities and
probabilities as well as the imagery and hierarchy of stressors on the
split-screen technique. The cognitive dialogue and behavioral techniques
I use have proven successful in my work.

Other approaches are worth discussing. For
example, Dr. Iraida Kazachkova, a psychiatrist at Lutheran Medical
Center and the Jewish Board of Family and Children Services, prefers a
more focused, highly structured method to achieve the same results
through cognitive restructuring desensitization and flooding.

Dr. Kazachkova would ask the patient: What
time does the panic attack
occur? What did you feel? What were your physical and emotional
symptoms?

For example, if the patient says, “I feel
like I'm choking and dying, and I must be going crazy,” through a
dialectic, Dr. Kazachkova will go back and forth with these three types
of questions, creating a dialogue that revisits the panic episode and the anxiety that
is felt in anticipation of this attack. Many of these panic attacks will come
paradoxically, so the ongoing repetitive dialogue is very important for
success.

She uses a series of maneuvers in increasing
and decreasing the intensity of the patient reliving the terror as these
three questions get reworked with a variety of new answers leading to
newer responses. She says that the flooding, desensitization, and
cognitive challenges, set up in a dialogue and sometimes including
material that is written down in preparation for a visit, are very
effective in clarifying what cognitions need to be challenged.

This cognitive restructuring is aimed at
helping the patient develop a coping mechanism in which the signs and
symptoms mean less and less as newer types of thinking replace the
fearful thoughts and terrifying physical symptoms. The anxiety, if it
occurs, simply passes. This allows the patient to separate from any
bodily symptoms that might occur.

This type of treatment, whether it uses my
LPA technique or Dr. Kazachkova's dialectical method, requires hard,
focused work on the part of the therapist. The aim of treatment is to
resolve the panicdisorder by thinking about it,
challenging it, and bringing new thoughts and a new reality into one's
own perception of the panic
situation. The goal is not to drift away in some form of traditional
psychodynamically oriented form of psychotherapy.

Many types of behavioral approaches to
treating panic disorders do
work. Finding one that fits you and your patient is an important part of
therapeutic success.

Panicdisorder treatment belongs
in the mental health area of practice. More anxiety disorders programs need to part of hospital
psychiatry programs so that these potential patients can get the care they need.

Let me know your thoughts and techniques on
treating panicdisorder, and I will try to pass
them along to my readers.